- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $986.83 / $1,006.53 / $1,498.65
| Professional | | $986.83 | $1,006.53 | $1,498.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,903.00 / $3,484.00 / $5,389.00
| Professional | | $2,903.00 | $3,484.00 | $5,389.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,137.97 / $1,844.63 / $2,606.15
| Professional | | $1,137.97 | $1,844.63 | $2,606.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,141.85 / $1,997.03 / $4,241.17
| Professional | | $1,141.85 | $1,997.03 | $4,241.17 |